Sunday, November 17, 2013

The Podium Of Good Clinical Practice

The Gold, Silver and Bronze Standards In Clinical Medicine

There is a correct and acknowledged relationship between the clinical acumen of the doctor and the technology that is at their disposal to help and support the clinician. The best, healthiest, safest, most certain and economical medicine is practiced by an experienced and talented clinician who wisely uses their clinical experience, skills and even intuition to use the science and technology of medicine wisely. The appropriate use of the technology available to medicine is in itself a part of their clinical arts. Another part of their clinical art is to be able to reliably interpret the results of investigations by placing them into the perspective and context of the clinical picture that includes all of the evidence from their clinical acumen.
This gold standard of medical practice is only achieved by the most exceptional doctors, the real geniuses of modern medicine. To reach this level requires immense amounts of scientific and clinical knowledge, outstanding clinical skills, brilliant thought processes and a vast experience.
The silver standard of medicine is the protocols and algorithms of modern Evidence Based Medicine which have been designed by the very best doctors mentioned above to try to imitate their thought processes and use of technology under normal circumstances. As such, they improve the standard of doctors that cannot live up to the gold standard of the medical profession, the truly exceptional and highly experienced doctors. If this is clearly understood and the algorithms and protocols are used correctly, they can become a learning experience for less experienced doctors along the path to becoming one of these gold standard masters of the clinical arts as well as masters of the science and technology.
However, these algorithms and protocols are second rate. They are poor imitations of the real thing. They only work reliably under usual circumstances. They fail in exceptional cases when patients and their diseases do not present or behave like the textbooks say that they should, which is not uncommon. They can also be confounded by the complexity of a modern medical reality in which many patients suffer multiple pathologies that interact with one another. Complexity is increased by factoring in the subjective influences and restrictions of the patients’ psychological and social situation. Then, only the brilliance, experience and intuition of an excellent doctor can cut through the complexity and produce a complex, holistic treatment plan.
Medicine where science and technology predominate over human clinical acumen and the clinician becomes subservient to their machines is at best third rate and does not deserve to be given a podium finish. It is not an end in itself. Properly understood, this style of medicine is taught in medical schools as fragments of a puzzle to be put together later as clinical acumen is learned through experience.
Medicine is not supposed to be practiced in the real world. The indiscriminate, knee-jerk use of science and technology in medicine for diagnosis, decision-making and treatment is dangerous. Every investigation and treatment that requires a doctor has a significant and measureable risk. The definition of a pharmaceutical product is significant side effects rather than effectiveness. Relatively safe products are classified as foods and supplements and many foods and supplements have therapeutic benefit.
Every scientific or technological investigation carries a risk, either directly or indirectly, the latter being largely the consequence of false positive results leading to further unnecessary investigation and treatment. Normality is defined by the results of 95% of the population and so for every parameter, five percent of the normal population has an abnormal result. In modern blood analysis a barrage of over twenty indices are measured ensuring the majority of normal, healthy people have at least one abnormal result. And sometimes scientific investigations do go wrong producing exactly the wrong result.
If the test result is inconsistent with the clinical picture, it is wrong and must be repeated. To do that requires that the doctor has great confidence in their clinical skills, more confidence in themselves than the science and technology of medicine.
And the interpretation and meaning of every test result is always dependent on the clinical context. In isolation, they say nothing. They have very poor discrimination between many conditions that can cause the same results.
The professional and public trust in the certainty of science and technology in medicine is a false hope. It has been repeatedly and categorically disproven. Science and technology without the clinical arts is a poor and dangerous way to practice medicine. The use and interpretation of the science and technology of medicine is an art in itself.
At least this third rate practice of medicine usually gets to the finishing line. Subjective medicine, which usually revolves around the doctor ingratiating themselves to their patients for popularity and cash invariably gets lost along the way and heads off in the wrong direction. This is the absolute antithesis of the clinical arts. The clinical arts are the objective use of subjective evidence. Subjective medicine is the subjective abuse of objective evidence.
To practice subjective medicine requires that the doctor throws all of their medical school education and experience out of the window for the most immoral and unethical motivations. This is what happens when medicine is practiced without the arts.
The root cause of this style of medicine is a society that confuses the lowest common denominator sales pitch of ‘The customer is always right’ with a life ethic or morality. Even in modern sales this passive aggressive, lose/win strategy is reserved only for conning the unwitting into buying worthless, inferior and overpriced products. In the end, it leads to both conflict and long term disaster. The win/win scenario is that the customer listens to and respects the knowledge and advice of the expert as they educate them into making a competent and informed decision in which they have also participated and understand.

  The present situation is that society is pressurising modern medicine into practicing a toxic mixture of subjective and technological medicine based on the false morality of ‘The customer is always right’ and their false certainty in science and technology. The only way that the senior medical profession can keep this in check is through the rigid imposition of the algorithms and protocols. This is dragging doctors towards a situation where medicine is at best second rate but in reality, corrupted below that level. The doctor becomes the sympathetic human interface to buffer the patients against the harsh reality of the algorithms and protocols and under constant pressure to ignore them for the sake of popularity, reputation and cash. That pressure is even stronger in uncoordinated private healthcare systems where the patient is permitted to shop around for a doctor who will say and do whatever they want.

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